Investigators: New York Nursing Facility Failed to Provide Adequate Treatment to Prevent Bedsores

According to a New York State Department of Health inspection conducted in December 2013, the Avon Nursing Home in Avon, New York, failed to provide adequate care to prevent a patient from developing stage II bedsores. The inspection report cited that the facility did not perform routine skin assessments and that staff members failed to notify doctors when the patient’s skin condition worsened. In June 2013, a patient suffering from a stroke and vascular disease was admitted into the nursing home. Because the resident already had a stage II pressure ulcer on his tailbone, a physician issued a standard order to treat the patient’s skin to prevent the sore from getting worse and to prevent further bedsores from forming. The orders required that staff members reposition the patient every two hours and to inspect the resident’s skin every morning and evening, as well as every time the patient was bathed.

When the patient had to go to the hospital in July 2013, hospital employees noticed that the patient had developed a stage II bedsore on the ankle. Moreover, DOH inspectors uncovered that over a period of four weeks during July 2013, nursing home staff failed to check the patient’s skin on 13 separate occasions. As a result, the resident developed four new bedsores–three of which were stage II and one which was unstageable. When left untreated, pressure ulcers can get worse and become infected. In serious cases, bedsores can lead to sepsis and gangrene, a condition in which tissue dies. Severe gangrene may require doctors to amputate the affected limb. On July 30, 2013, the patient had to be hospitalized for a high fever and a rapid heartbeat.

In another incident, the facility was cited for failing to properly care for a resident who had just undergone open-heart surgery. After being discharged from the hospital in June 2013, the patient was admitted to the Avon Nursing Home; the hospital discharge plan included detailed and explicit instructions on how to care for the patient after the surgery. For instance, the hospital’s instructions stated that the resident needed to be placed on a restricted diet that included low fat, low cholesterol and low sodium foods. In addition, the hospital instructed that the patient wear TED stockings and to use a special device to improve breathing. Moreover, staff members were instructed to help the patient with “sternal precautions,” which include coughing and deep breathing exercises.

Contrary to the discharge orders, the nursing home’s physician never ordered or instructed staff members to do any of the things outlined in the hospital discharge plans. In late June, staff members noted that the patient was having difficulty breathing. Shortly thereafter, the patient was diagnosed with pneumonia. In late July, the patient had to be hospitalized for a fever and low oxygen levels. DOH investigators pointed out in their report that a similar incident had occurred at the facility in January 2013.

Overall, the “Nursing Home Compare” website gave the facility a much below average rating. The facility received much below average ratings for staffing levels and health inspection results.